Billing Patients

A patient comes to see a provider, a waiver is signed, claim is submitted and has denied. Now it has denied as CO (contractual obligation) and not PR (patient responsibility).. Since this patient signed a waiver, can you legally bill them for the denied services?

I cannot find any material to tell me yes or no.

Thank you for your time.

re: Billing Patients

If the provider is contracted with the insurance company, then no you can't bill the patient. If it denied as a non-covered service then you can bill the patient. Why did the insurance company deny? Was it billed correctly? I'm also curious as to why you had the patient sign a waiver because if you knew it wouldn't be covered, why didn't you just have patient pay up front?

re: Billing Patients

When you say denied non covered, the denial code can be either CO, or PR, so if it denies Non Covered with a CO denial are you indicating you can bill the patient? I know that if denied with a PR, yes..

Yes, billed correctly, cases I am seeing are "we are not the pcp", so they have patient sign a waiver and see them, and bill the insurance company.

I am trying to gather information to assist in changing the policy, but need reference material to prove to them.

Any ideas?

re: Billing Patients

Are you a participating provider with this insurance company? If no, then you can bill the patient, no matter what the EOB says. If you are a participating provider and you saw the patient, knowing you weren't the PCP (which you did because you had them sign a waiver) then I would say no, you cannot bill the patient. I would say that in the future, do not even bill the insurance company and require the patient to pay up front.

If you are a participating provider, then your contract would be your reference as to when you can and cannot bill the patient.

re: Billing Patients

Thank you for your assistance and information. It is greatly appreciated.